Eating DisorDErs: Best Practices in Prevention and intervention

Eating Disorders:
Best Practices
in
Prevention and Intervention
Mental Health and Spiritual Health Care
Manitoba Health
In Partnership with the Manitoba Network on
Disordered Eating/ Eating Disorders
2006
Table of Contents
1.
INTRODUCTION
1.1
Page 1
Background
1.1.1The Eating Disorders Continuum 1.1.2Anorexia nervosa, bulimia nervosa and binge eating disorder
1.1.2.1 Anorexia Nervosa
1.1.2.2 Bulimia Nervosa
1.1.2.3 Binge Eating Disorder
1.1.3
Prevalence Rates
1.1.3.1 Female
1.1.3.2 Male 1.1.4 Co-morbidity with other Psychiatric Diagnoses
1.1.5
Mortality Statistics
1.1.6Complexity / Multifactorial Nature of Causality
1.1.6.1 Risk Factors
1.1.7 Protective Factors
2. BEST / PROMISING PRACTICES – PREVENTION Page 2
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Page 4
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1.1
1.2
Models of Prevention
Elements of Best Practice
1.2.1
Do No Harm
1.2.2
Enhance Self-Esteem
1.2.3
Facilitate Media Literacy
1.2.4
Facilitate Peer Support
1.2.5
Include Boys and Girls
Page 5
Page 7
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Page 6
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1.3
Building Capacity in Key Stakeholders
1.3.1
Parents
1.3.2Teachers & Other School Personnel
1.3.3Coaches
1.3.4
Pediatricians and General Practitioners
Page 7
Page 7
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3. BEST / PROMISING PRACTICES – IDENTIFICATION 1.1
4.
Page 1
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Page 2
Mechanisms for Identification
1.1.1
Pre-teen and Adolescent Girls
1.1.2Adolescents with Type 1 Diabetes
1.1.3Adult women
1.1.4
Individuals in High Risk Occupations
And activities
BEST / PROMISING PRACTICES – INTERVENTION
1.2
Elements of Intervention for All Eating Disorders
1.2.1
Early Identification and Intervention
1.2.2Community based
1.2.3Access to Needed Services across Continuum
1.2.4
Multi-disciplinary/Interdisciplinary Eating Disorders: Best Practices in Prevention and Intervention
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Table of Contents
1.3
1.2.5Age appropriate
1.2.6
Involvement of Natural Supports
1.2.7
Involvement of Individual in planning
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Page 11
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Key Components of Therapeutic Relationship
1.3.1Collaboration
1.3.2Respect for individuality
1.3.3
Honesty
1.3.4
Patience and curiosity
1.3.5
Emphasis on experimentation
1.3.6
Focus on Functionality of beliefs
1.3.7Systematic/Outcome focus
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1.4Therapeutic Models and Approaches
1.4.1Anorexia Nervosa
1.4.1.1Cognitive Behavioural Therapy (CBT)
1.4.1.2
Family-Based Therapy
1.4.1.3
Interpersonal Psychotherapy
1.4.1.4
Psychoeducation
1.4.1.5
Motivational Enhancement (MET)
1.4.1.6
Experiential Therapy
1.4.1.7
Psychodynamic Therapy
1.4.1.8
Feminist Therapy
1.4.1.9
Pharmacotherapy
1.4.1.10
Follow-up / Relapse Prevention 1.4.1.11Shortcomings in Research
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1.4.2
Bulimia Nervosa
1.4.2.1Cognitive Behavioural Therapy
1.4.2.2
Guided Self-Help
1.4.2.3
Interpersonal Psychotherapy
1.4.2.4
Pharmacotherapy
1.4.2.5
Dialectical Behaviour Therapy
1.4.2.6
Exposure and Response Prevention
1.4.2.7
Psychodynamic Therapy
1.4.2.8
Feminist Therapy
1.4.2.9
Experiential Therapy
1.4.2.10
Follow-up / Relapse Prevention
Page 15
Page 15
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1.4.3
Binge Eating Disorder
1.4.3.1Cognitive Behavioural Therapy (CBT)
1.4.3.2
Guided Self-Help
1.4.3.3
Interpersonal Psychotherapy
1.4.3.4
Pharmacotherapy
1.4.3.5
Dialectical Behaviour Therapy
1.4.3.6
Psychodynamic Therapy
1.4.3.7
Feminist Therapy
1.4.3.8
Experiential Therapy 1.4.3.9
Follow-Up / Relapse Prevention
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Eating Disorders: Best Practices in Prevention and Intervention
Introduction
BACKGROUND
The Eating Disorders Continuum
Eating disorders can be viewed as occurring along a
continuous line, with normal eating at one end and
clinically diagnosed and treated eating disorders at
the other. The idea is useful in highlighting how body
image, weight and eating problems are related. It also
acknowledges the differences in the seriousness of the
problems.
While there are variations on the linear idea, they all
illustrate the idea that eating disorders are related to their
life situations, stressors and social contexts.
Eating disorders don’t always develop in a linear fashion,
though. There are various ways they develop. The British
Columbia Eating Disorders Program has developed the
following chart to illustrate the range of behaviours on
the disordered eating continuum.
Table 1: The Continuum of Disordered Eating
Wellness
Unhealthy Eating Behaviours
Occurring most of the
time:
Unhealthy eating behaviours and attitudes
increase in frequency and intensity:
• realistic, positive body
image
• feeling fat, worried about appearance, size,
shape
• eating and drinking
only when hungry or
thirsty
• preoccupied with food, weight, exercise,
looks
• positive attitude and
balanced approach to
food choices
• positive attitude and
balanced approach to
physical activity choices
• not using food in response to body signals,
but eating for comfort or as a response to
depression, boredom
• not eating due to depression or selfpunishment
• postponing or cancelling activities (ex: beach)
due to weight, size, appearance
• dieting, restricting, fasting, binging, purging,
compulsive eating
Eating Disorders
Unhealthy eating
behaviours are
labelled as eating
disorders once they
have reached a point
where they can be
formally diagnosed.
Traditionally,
eating disorders
are separated into
categories:
• anorexia nervosa
• bulimia nervosa
• compulsive or binge
eating
• compulsive exercising
Usually, as more energy is spent on unhealthy
behaviours and attitudes, less energy is
available for life’s activities (ex: school, work,
family, friends, hobbies).
Anorexia Nervosa, Bulimia Nervosa
and Binge Eating Disorder
Anorexia Nervosa
Individuals with anorexia nervosa have a markedly
restricted caloric intake, strange dietary rules and
may exercise compulsively. The Diagnostic and
Statistical Manual of Mental Disorders - Fourth
Edition (DSM-IV) provides the following diagnostic
criteria for anorexia nervosa:
Anorexia nervosa and bulimia nervosa are both
characterized by a preoccupation with weight and a
desire to be thinner. They are not mutually exclusive
in that 50 per cent of anorexic patients will also
have bulimia. The disorders are diagnosed using
recognized criteria.
•
an intense fear of gaining weight
•
a refusal to maintain adequate nutrition, often
associated with an erroneous image of the self
as fat
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Eating Disorders: Best Practices in Prevention and Intervention
• loss of original body weight to 85 per cent or less
of what is expected for normal height and weight
• eating alone because they are embarrassed by
how much they are eating
• disturbance of body image and negative selfevaluation
• feeling disgusted with themselves, depressed or
very guilty after overeating
• absence of at least three consecutive menstrual
periods in females who have started menstruating
Co-Morbidity
Sources point to the high incidence of co-morbid
psychiatric conditions among individuals with
anorexia nervosa, bulimia nervosa and binge eating
disorder (Spindler et al, 2004; Kotwal et al, 2004;
Grilo et al, 2003; Woodside et al, 2001; APA, 2000).
Findings by the American Psychiatric Association
Work Group on Eating Disorders (2000) found that:
Anorexia nervosa is also defined as restricting type,
during which no binging or purging behaviour
occurs, or as binge-eating/purging type characterized
by binge eating, self-induced vomiting or misuse of
laxatives, diuretics or enemas.
Bulimia Nervosa
• 50 to 70 per cent of the clients experienced mild
to severe depression
According to the DSM-IV, bulimia nervosa is
characterized by:
• four to six per cent had bipolar disorder
• frequent binge eating episodes accompanied by a
sense of loss of control
• 25 per cent had obsessive compulsive symptoms
• recurrent inappropriate behaviour (ex: vomiting,
use of laxatives, fasting, excessive exercise)
intended to prevent weight gain
• 42 to 75 per cent had a personality disorder
• both of the above behaviours occur at least twice
a week, on average, for three months
In an Ontario study (Woodside et al, 2001) which
compared males and females with eating disorders,
there were marked similarities in terms of co-morbid
psychiatric diagnoses, with the exception of sexual
abuse, which was higher for women.
• 20 to 50 per cent had been sexually abused
• self-evaluation is excessively influenced by body
shape and weight
Bulimia is divided into purging type and non-purging
type with the latter characterized by obsessive
exercising.
Complexity/Multifactor Nature of
Causality
While there is a substantial body of research
establishing the complex interplay of socio-cultural,
developmental, psychological, familial, and biological
factors, there remains a lack of consensus as to the
etiology of anorexia and bulimia (Steiger, 2004).
Kreipe & Birndorf (2000) suggest that this complexity
might be addressed by viewing eating disorders
as “a final common pathway having multiple
determinants” (p.1030).
Binge Eating Disorder
The DSM-IV classifies binge eating disorder as an
eating disorder not otherwise specified, which is a
category containing significant eating disorders that
do not fit clearly into anorexia nervosa or bulimia
nervosa. The DSM-IV defines binge-eating disorder as:
• binge eating episodes accompanied by a sense of
loss of control
The following section provides a brief review of
resiliency theory and risk and protective factors that
assist in understanding possible contributing factors
to disordered eating and eating disorders.
• no inappropriate behaviour to prevent weight
gain
• the behaviour occurs at least twice a week, on
average, for three months
Risk Factors
In order to be diagnosed as binge eating disorder, the
binge-eating episodes must have three or more of
the following characteristics
Similar to addictions research, while there is a general
consensus as to the complexity of contributing
factors, few have been empirically validated as direct
causal risk factors. (Abraham, 2003; Barr Taylor et al,
2003; Pritts & Susman, 2003; Mitan, 2002; Johnson
et al, 2002; AMA, 2002; Strieger-Moore et al, 2002;
• eating more rapidly than normal
• eating until feeling uncomfortably full
• eating large amounts of food when not hungry
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Eating Disorders: Best Practices in Prevention and Intervention
Rohwer & Massey-Stokes, 2001; ADA, 2001; Piran,
2001; Kriepe & Birndorf, 2000; Mussell et al, 2000;
Wilhelm & Clarke, 1998).
behaviour is reported in girls as young as 10 years
(McVey et al, 2004).
Those involved in the field of eating disorders
prevention are concerned that the current focus
on reducing obesity in children, although wellintentioned, may inadvertently increase disordered
eating behaviours because “overweight, perceived
overweight and weight concerns are known to
precede dieting, hazardous weight loss behaviour
and eating disturbances” (O’Dea, 2002, p.91).
Of all direct risk factors, the most significant risk
factor for the development of an eating disorder is
dieting behaviour (McVey et al, 2004; AMA, 2002;
Tozzi et al, 2002; Rohwer & Massey-Stokes, as
cited in Peters, 2003; Gilchrist et al, 1998). A recent
Canadian study found that unhealthy dieting
Table 2: Summary of Possible Risk Factors for the
Development of Eating Disorders
Eating Specific Factors
(Direct Risk Factors)
• Eating disorder – specific genetic risk
Biological
Factors
Psychological
Factors
Generalized Factors
(Indirect Risk Factors)
• Body weight
• Genetic risk for associated mental
health disturbance
• Appetite regulation
• Temperament / Impulsivity
• Energy metabolism
• Neurobiology mechanisms
• Gender
• Gender
• Poor body image
• Poor self-image
• Maladaptive eating attitudes
• Inadequate coping mechanisms
• Maladaptive weight beliefs
• Self-regulation problems
• Specific values or meanings assigned
to food or body
• Unresolved conflicts, deficits,
posttraumatic reactions
• Overvaluation of appearance
• Identity and autonomy issues
• Overprotection
Developmental
Factors
• Identifications with body-concerned
relatives or peers
• Aversive mealtime experiences
• Trauma affecting bodily experience
• Neglect
• Felt rejection, criticism
• Traumata
• Interpersonal experience
• Family dysfunction
Social and
Cultural Factors
• Maladaptive family attitudes to
eating, weight
• Negative peer experiences
• Peer-group weight concerns
• Social values detrimental to stable
positive self-image
• Pressures to be thin
• Destabilizing social change
• Body-relevant insults, teasing
• Specific pressures to control weight
(ex: ballet, sports)
• Maladaptive cultural values assigned
to body
• Values assigned to gender
• Social isolation
• Poor support network
• Impediments to means of selfdefinition
Source: Health Canada. (2002). A Report on Mental Illnesses in Canada, p. 83
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Eating Disorders: Best Practices in Prevention and Intervention
Protective Factors
Protective factors decrease the likelihood that a
problem will develop. A protective factor is not simply
the absence of a risk factor, however protective
factors may emerge in response to risk factors — for
example, when healthy adaptation or coping result
as a response to trauma. Table 3 provides a list of
protective factors that are specific to eating disorders
and a list of those generally associated with mental
health.
Table 3: Protective Factors
Direct and Indirect
Specific to Eating Disorders
• Positive body experience, including an
understanding of normal pubertal changes
• Healthy eating and exercise habits
• An understanding of normal nutrition
• Understanding that food is neither good nor
bad and that eating is an enjoyable, normal
behaviour
• Lack of pressure to conform or be praised based
on weight and shape
General for Overall Mental Health
• High self-esteem, confidence and self-respect
• Confidence in expressing one’s needs and emotions
• Optimism
• Self-awareness about own feelings
• Healthy stress management, coping, problemsolving skills and assertiveness
• Social competency
• Supportive relationships
• Community definitions of beauty that focus on
self-respect, assertiveness and generosity of spirit
• Family stability and cohesiveness, healthy conflict
resolution
• Competent adult role models of all shapes and
sizes who are praised for their accomplishments
• Encouragements of self-expression
• Mentoring by adults outside the nuclear family
• Clear and positive social norms at the community
level and clear and fair rules
• Strong communal coping and local community
traditions of inclusion
• Inter-generational communication and involvement
• Respect for children and youth – their inclusion and
participation as members of society in their own
right
• Respect for cultural diversity
Source: The Eating Disorder Resource Centre of British Columbia. (2001). Preventing Disordered Eating: A Manual to Promote Best Practices for
Working with Children, Youth, Families and Communities, pp.16-17.
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Eating Disorders: Best Practices in Prevention and Intervention
Best/Promising Practices In Prevention
Models of Prevention
Research on the prevention of disordered eating
is very new and far from definitive. Wener’s 2003
review of prevention literature concluded that there
is not enough evidence to allow for clear statements
about what is best practice. The Eating Disorders
Program of British Columbia states in its eating
disorders prevention manual that this will change
over time and that “as the number of prevention
programs and body of research expands, knowledge
of, and confidence in best practice strategies will
grow.” (2001, p.6)
Levine & Piran (2001) provide a useful context for
examining different prevention approaches in their
review of the Disease-Specific Pathway (DSP) model,
the Non-Specific Vulnerability Stressor (NSVS) model
and the Ecological model. Prevention programs tend
to contain elements from both the DSP and NSVS
models, and, to a lesser extent, the ecological model
(see Table 4).
Table 4 – Prevention Models
Disease Specific Pathway
(DSP) Model
Non-Specific Vulnerability
Stressor (NSVS) Model
• Nutrition and exercise for
healthy weight control
• Nutrition and exercise as part of
a healthy lifestyle
• Nature and danger of calorierestrictive dieting
• Life skills (assertiveness,
relaxation)
• Individual strategies for
analyzing and resisting
unchanging cultural factors
• Improvement of general selfesteem and sense of competence
• Nature and dangers of eating
disorders
• Development of social support
Ecological Model
• Changing attitudes and
behaviours (parents, teachers
and other significant adults)
• Creating healthier values and
norms (peers and community)
• Collective efforts to transform
socio-cultural influences
(media)
• Critical thinking about gender
• Developmental factors such as
weight gain during puberty.
Source: Levine, M. & Piran, N. (2001). The prevention of eating disorders: Toward a participatory ecology of Knowledge, action and advocacy. In
Striegel-Moore & Smolak (eds.) Eating Disorders: Innovative directions in research and practice. Washington, DC: APA.
Elements of Best Practice
• not address eating disorders without placing them
within the entire context of the continuum
Current knowledge about prevention provides
cautions around some components of the DSP model
and emphasizes the merits of elements from the NSVS
and Ecological models (as described in Table 4).
• place the emphasis on positive body image and
the dangers of dieting – not on specific eating
disorders or their causes
• never address how to be eating disordered (ex:
vomiting, laxative use, etc.)
Do No Harm
There are cautions provided by a number of sources
(O’Dea, 2002; Russell & Ryder, 2001; Crago et
al, 2001, as cited in Peters, 2003) that prevention
programs containing symptom-specific education may,
inadvertently, be more of a risk than a benefit because
they provide information about behaviours such as
vomiting or laxative use. Russell & Ryder (2001)
address this concern and recommend that prevention
materials and education:
Enhancing Self Esteem
Enhancing self-esteem is viewed as integral to
successful eating disorders prevention because it has
been identified as both a risk and protective factor for
the development of a negative body image and eating
problems. (McVey, 2003; Peters, 2003; Piran, 2001;
O’Dea & Maloney, 2000). For example:
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Eating Disorders: Best Practices in Prevention and Intervention
Facilitate Peer Support
• children with high self-esteem are better able to
cope with teasing, criticism, stress and anxiety –
all of which are associated with eating problems.
Peers and friendship groups contribute significantly to
the development of perceptions around body image
and related behaviours. In their manual, the Eating
Disorders Resource Centre of British Columbia (EDRC
of BC) notes the tendency to focus on negative
aspects of peer relationships (ex: peer pressure) rather
than recognizing and capitalizing on the supportive
nature of friendships (EDRC, 2001). The manual
suggests that effective prevention programming
needs to recognize the positive aspects of peer
groups and friendship networks as a mechanism for:
• developing self-esteem helps children to
recognize and value their strengths, be more selfaccepting and less likely to obsess about being
perfect. Perfectionism is strongly linked with body
image issues and eating disorders.
Of particular merit is programming that increases
self-identity and a sense of self-worth by focusing
on the multi-faceted aspects of self, the value of
diversity and moves students away from an overemphasis on appearance and focus on weight, food
and dieting (Abraham, 2003; O’Dea, 2002).
• working together to explore healthy approaches
to eating and being active
• building skills (ex: responding effectively to
bullying or teasing about shape and weight)
Facilitate Media Literacy
Western culture equates beauty and happiness with
an extremely thin body shape, and this message
is promoted relentlessly by our media. Canadian,
American, Australian and British sources all note that
children are exposed to this message from an early
age and without media literacy skills, they are unlikely
to question its validity (AMA, 2002; Friedman, 2000;
McVey, 2003). Smolak (1999) demonstrates how
unreachable the current cultural ideal is for women:
In addition, age appropriate training in basic helping
skills (ex: communication skills, problem solving,
conflict resolution), ethics, confidentiality and referral
processes, capitalizes on existing peer influences and
provides peers with the skills to help one another.
Older peers can also act as mentors for younger
peers. (EDRC, 2001)
Include Boys and Girls
• the average woman in the United States is 5’4”,
weighs 144 lbs. and wears a size 12 or 14.
While most prevention programming has been
focused on girls, recent studies have identified an
increase in body image issues and eating problems
in boys and young men. O’Dea notes that “young
male adolescents are known to be concerned about
their body image and size, and engage in dieting and
steroid abuse.” (2002, p. 89)
• the average American model is 5’11, weight 117
and represents two per cent of the population.
• media images of women represent only five per
cent of the female population. Ninety-five per
cent do not match the cultural ideal.
Media literacy training provides children and
adolescents with the knowledge and skills needed
to question what they see in the media and to
understand, in very specific ways, how it does not
reflect reality [ex: that a magazine cover model has
been digitally altered and airbrushed] (Friedman,
2002; Cavanaugh & Lemberg, 1999; Gordon, 2000;
Jambor, 2001). A study by Wade and colleagues
(2003) found that students involved in media literacy
groups demonstrated less internalization of society’s
thin ideal than participants in control groups.
McVey (2003) describes the following benefits
associated with educating boys about body image
issues:
• helping them to deal with their own body image
issues and unhealthy practices related to eating
and exercise
• facilitating an awareness about the intense
pressure faced by female students
• helping boys, as well as girls, to understand why
school policies are put in place about harassment
and teasing about weight and shape
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Eating Disorders: Best Practices in Prevention and Intervention
Building Capacity in Key Stakeholders
Parents
children and do not always provide reading materials
for parents.
Parents are children’s first teachers and role
models. They continue to be a significant influence
throughout childhood and adolescence. They are
critical to effective prevention. Russell & Ryder (2001)
point out that because parents have been exposed
to societal norms and messages about shape, weight
and food, it should not be assumed that they have
the understanding and skills to help their child to
develop a positive body image. Many parents will
require information and skill building that will allow
them to:
Teachers and Other School Staff
Because children spend so much of their time at
school, school personnel are also key influences.
Teachers, coaches and administrators need to be
aware of their attitudes and behaviours concerning
shape, weight and food. They need to be aware of
the messages they are sending. School personnel
are likely to require additional training to be able to
encourage a body friendly environment (Friedman,
2003; EDRC of BC, 2001; Smolak, as cited in Peters,
2003) where teachers and other school staff:
• understand how societal attitudes and prejudices
have influenced their own beliefs, attitudes and
behaviours about their bodies and the bodies of
others, their reasons for exercising, the way they
label foods as bad, safe, dangerous, and fattening
• place an emphasis on building self-esteem, selfassertion, critical thinking and communication
skills
• model positive attitudes and practices around
shape, weight and food
• teach their children about different body types
and the importance of who a person is, not what
they look like
• put in effect policy or administrative procedures
to deal with sexual harassment and teasing based
upon weight and shape
• send clear messages to children that they are
valued and accepted for qualities other than how
they look
• realize that some standard practices (ex: weight
categories in sports) may have negative effects
on vulnerable students and use discretion in
changing those practices to accommodate
individual needs
• discuss with their children:
• the dangers of trying to change one’s body
through dieting or other body altering
behaviours
[ex: steroids]
McVey et al (2004) report that formal training of
educators about body image issues, and eating
disorders prevention is underway in Ontario at the
present time.
• the benefits of being active
• the importance of eating a variety of foods
(avoid labelling foods as good, bad, etc.)
Coaches
• be role models for sensible eating, emphasizing
through words and behaviour that healthy eating
is an essential part of normal daily living and good
quality food is needed as fuel for our bodies
Adolescents and young adults involved in
ballet, gymnastics and competitive sports may
be particularly high risk due to longstanding
requirements and expectations around body shape
and weight. Sources (Vaughan et al, 2004; Piran,
2001) stress that instructors and coaches need
to be well informed and unbiased while openly
encouraging adolescents to make healthy choices.
• talk about the importance of self-acceptance and
encourage children to practice being their own
best friend and to control self-talk by replacing
negative with positive messages. (Russell & Ryder,
2001)
Piran (2001) points out that current eating disorders
prevention packages in many schools focus mainly on
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Eating Disorders: Best Practices in Prevention and Intervention
Pediatricians and General Practitioners
Pediatricians and General Practitioners (GPs) are
frequently the first points of contact for individuals
with an eating disorder. As such, they are in a key
position to increase public awareness about the risks
of restrictive dieting (AMA, 2003; APA, 2003). This
can be done in a number of ways, including the
promotion of healthier attitudes towards weight and
shape, and provision of sound nutritional advice.
Abraham (2003) recommends that all practitioners:
The guidelines also state that, given the high
prevalence of dieting behaviour in adolescent girls,
screening for disordered eating should be a part of
routine health care (for full guidelines see www.cps.
ca/english/statements/AM/AH04-01.htm)
Both the American Academy of Pediatrics (2003)
and the Australian Medical Association (2002)
recommend that medical practitioners examine
their own beliefs and prejudices around weight and
shape, as these may inadvertently add to stress
and unhealthy choices. The AAP recommends
practitioners advise against the use of strict diets for
weight loss and that pediatricians be aware of the
careful balance that needs to be in place to decrease
the growing prevalence of eating disorders in children
and adolescents. When counselling children on the
risk of obesity and healthy eating, care needs to be
taken not to foster overaggressive dieting and to help
children and adolescents build self-esteem while still
addressing weight concerns (AAP, 2003).
• engage in continuing education regarding healthy
attitudes, practices and beliefs about food, eating,
exercise and body weight for young people
• when talking with adolescents, be aware of
possible risk, trigger and perpetuating factors
associated with eating and exercise problems
Since childhood overweight has been identified
as a pressing problem, unintended consequences
have become a key concern. The Canadian
Pediatric Society (CPS) addressed this issue with the
publication of their 2004 best practice guidelines
which cautions pediatricians and recommends that
they:
• discourage fad diets, fasting, skipping meals and
dietary supplements to achieve weight loss
• advise teenagers to be wary of any weight loss
scheme that tries to sell them anything, such as
pills, vitamin shots or meal replacements.
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Eating Disorders: Best Practices in Prevention and Intervention
Best/Promising Practices In Identification
Early detection and treatment of eating disorders is
strongly correlated with better outcomes (Abraham,
2003, Marks et al, 2003; Rome et al, 2003; Mitan,
2002). The literature reviewed consistently stresses
the need to increase capacity to identify and
intervene early. While acknowledging the secrecy
that characterizes eating disorders makes this
challenging, sources reviewed point to a number of
relatively straightforward ways to work toward this
goal.
excellent position to identify at risk behaviour
and respond effectively.
Health Care Practitioners: The capacity of health
care practitioners to identify eating disorders in
pre-teens and adolescents is yet to be realized.
Existing guidelines and literature concur that
simple screening questions about eating patterns
and satisfaction with body appearance should be
routinely asked of all pre-teens and adolescents
(NICE, 2004; AAP, 2003; EDAQ, 2000; Russell &
Carr, 2003; Marks et al, 2003; Rome et al, 2003;
Pritts & Susman, 2003).
Mechanisms for
Identification
The Canadian Pediatric Society (2004) and the
American Academy of Pediatrics (2003) both
emphasize that health care professionals need to
take the developmental process of adolescence
into account, and that a strict reliance on DSMIV diagnostic criteria is inadequate because
of the nature of physical and psychosocial
development. The CPS (2004) guidelines state:
The work that has been done on identifying high
risk groups of individuals provides a solid foundation
for strategy development in improving rates of early
identification. Research has highlighted the following
groups as being more high risk:
• pre-teen and adolescent girls
• girls and women involved in competitive sports,
modeling and ballet
. . . the use of strict criteria may
preclude the recognition of
eating disorders in their early
stages and sub-clinical form
and . . . may exclude some
adolescents with significantly
abnormal eating attitudes and
behaviours. Finally, abnormal
eating habits may result in
significant impairment in
health, even in the absence
of fulfillment of formal criteria
for an eating disorder. For all
of these reasons, it is essential
to diagnose eating disorders
in adolescents in the context
of the multiple and varied
aspects of normal growth
during puberty, adolescent
development, and the eventual
attainment of a healthy
adulthood, rather than by
merely applying formalized
criteria (2004, p.190).
• females and males in competitive sport (running,
gymnastics) and other activities (modeling, ballet)
that place strong emphasis on body shape and
weight
Pre-Teen and Adolescent Girls
The number of people involved in the lives of
pre-teen and adolescent girls is generally larger
than for any other group. It includes parents,
pediatricians, general practitioners, gym teachers and
school counsellors. This reality provides numerous
opportunities to employ effective formal and informal
mechanisms for identifying disordered eating and
eating disorders.
Parents: As with prevention, parents are central
to any plan to ensure early identification of
children and adolescents with disordered eating
patterns. Parents’ ability to identify eating
disorders early is dependent upon possessing the
requisite information. In addition, they require
access to information about available resources
for their child and the family as a whole.
As with other stakeholder groups, there is a need
to ensure that practitioners possess the requisite
information in order to optimize the effective
implementation of guidelines and research findings.
School Personnel: Teachers, coaches, counsellors
and other school staff spend a great deal of
time with pre-teen and adolescent girls. Given
adequate information about eating disorders
and available resources, school staff are in an
9
Eating Disorders: Best Practices in Prevention and Intervention
Adolescents with Type 1 Diabetes
Again, a sufficient knowledge of eating disorders is a
requirement for this to be an effective mechanism.
Jones and colleagues (2000) found that DSM-IV and
sub-threshold eating disorders were twice as common
in adolescents with Type 1 diabetes.
Individuals in High Risk Occupations
and Activities
Young women with Type1 diabetes mellitus are cited
as being particularly at risk for developing eating
disorders because insulin omission is a common
weight loss practice among women with Type 1
diabetes mellitus.
There are also higher rates of eating disorders in
female and male competitive athletes. Studies show
that young female athletes who are high risk for
developing disordered eating patterns and eating
disorders are those who are involved in sports that
emphasize leanness such as gymnastics, track and
field, figure skating, cross-country and swimming
(Black et al, 2003; Smolak et al, 2000). Black and
colleagues’ 2003 study of college and university
athletes found prevalence rates of eating disorders
in 33 per cent of cheerleaders, and disordered eating
in 50 per cent of gymnasts, 45 per cent of modern
dancers and 45 per cent of cross-country athletes.
Meltzer et al (2001) point to studies showing that
15 to 40 per cent of young women with Type 1
diabetes engage in insulin omission or reduction,
which results in calorie purging and rapid weight loss.
Under-dosing on insulin has the potential for serious
side effects including microvascular (ex: retinopathy)
and metabolic complications (Pritt & Susman, 2003;
Walsh et al, 2000).
Coaches and instructors: Coaches and instructors
who work with adolescents and young adults in
competitive sports, ballet, gymnastics, weightlifting
and wrestling are in an excellent position to identify
individuals who appear at high risk for developing an
eating disorder.
Family members, school personnel and health care
practitioners can all be effective in identifying at risk
behaviour in this sub-group of adolescent girls.
Adult Women
Research has found that, during the five years
preceding the diagnosis of an eating disorder, women
go to medical practitioners markedly more often than
women without eating disorders. Sources (Marks
et al, 2003; Hay, 2003; Mehler, 2001; Wilhelm &
Clarke, 1998) note that while individuals are often
reluctant to go to a physician with an eating disorder
they may present with symptoms, like low BMI,
amenorrhea or gastrointestinal complaints, all of
which may appear unrelated. These sources assert
that health care practitioners should suspect eating
disorders in women who present with:
Vaughan et al (2004) focus on post-secondary
institutions and make the following recommendations
for supporting coaches and instructors to develop the
capacity for identification:
• Post-secondary institutions should have eating
disorders policies and procedures, as there is
evidence that these increase the knowledge
of coaches and instructors, and increase their
capacity to identify and respond to athletes with
eating disorders.
• Education and training should be provided by
universities and be made available to athletic
trainers, coaches and athletes.
• low body mass index (BMI) compared with age
norms
• There should be referral mechanisms in place
for dieticians, counsellors and psychologists with
expertise in eating disorders.
• weight concerns when they are not overweight
• menstrual disturbances or amenorrhea
• gastrointestinal symptoms
This study found that female coaches possess
more knowledge of eating disorders and are more
confident about approaching an athlete having
difficulties. Given this, there is a recommendation
that male coaches be targeted for additional training
and education.
• physical signs of starvation or repeated vomiting
• Type 1 diabetes and poor treatment adherence
• co-morbid concerns such as depression, anxiety
and substance abuse
Healthcare practitioners: As with other high risk
populations, the regular use of screening questions
would help in alerting health care practitioners to
disordered eating and eating disorders.
Also, it is recommended that questions about poor
body image and dieting be part of a systematic
lifestyle risk assessment when taking a medical
history (Luck et al, 2002; AMA, 2003).
10
Eating Disorders: Best Practices in Prevention and Intervention
Best/Promising Practice – Intervention
Multidisciplinary/Interdisciplinary
While the evidence base related to effective
treatment of eating disorders is expanding rapidly,
there is still a lack of definitive research findings
and there are still major gaps in knowledge (NICE,
2004; Bergh et al, 2002). As with prevention and
identification, best practices in intervention are based
on the most recent information available and will
continue to evolve.
A multidisciplinary/interdisciplinary team should
be involved during the assessment and ongoing
treatment of eating disorders (ex: medical,
nursing, nutritional, and mental health disciplines).
Psychological treatment provided should focus on
eating behaviour, attitudes to weight/shape and
wider psychosocial issues.
This section presents best practice themes derived
from a number of guidelines, recommendations,
and other best practices literature from Canada, the
United States, Australia and Britain. The most recently
compiled guidelines were published in January of
2004 by the National Institute for Clinical Excellence
(NICE) in Britain. Other recent guidelines reviewed
include those from the Canadian Pediatric Society
(1998, reaffirmed in February 2004), the American
Psychiatric Association (2000), American Academy
of Pediatrics (2003), Australia Medical Association
(2002) and American Dietetic Association (2001).
Age Appropriate
Eating disorders treatment for children and
adolescents should be appropriate to their physical
and psychological developmental stage, should
involve family members and should balance
treatment needs with social and educational needs
wherever possible.
Involvement of Natural Supports
Family and other natural supports should be offered
education and information on eating disorders and
be linked to resources including self-help and support
groups.
Elements of Intervention for
All Eating Disorders
There is a significant consensus on key elements of
successful eating disorder intervention that apply
across diagnoses. These elements are also reflective
of the principles of mental health renewal in
Manitoba.
Consumer Involvement
Consumers should have an active role in the
treatment process, with individual needs, goals and
preferences being considered during the development
and implementation of a treatment plan.
Early Identification and Intervention
It is widely accepted that early identification and
intervention are strongly linked to positive results.
To achieve this requires proactive measures such as
routine screening of high risk groups.
Key Components of a
Successful Therapeutic
Relationship
Literature reviewed highlights the importance of
a positive therapeutic relationship, and identifies
components of the therapeutic approach that has
been found to be most effective in working with
individuals with eating disorders (NICE, 2004;
Vitousek & Watson, 1998; Clinton, 1996). These are
outlined below.
Community Based
Interventions for individuals should be communitybased wherever possible. Clinical research and
guidelines reviewed concur that nearly all individuals
can be successfully treated in community settings.
Hospitalization should be considered only when an
individual is severely medically compromised or at risk
of serious self-harm.
Collaboration
The best possible results are realized when the
therapeutic approach is based on a collaborative
partnership between the individual and therapist,
rather than being didactic and expert-driven.
Access to Services and Supports
across the Continuum
Individuals should have timely access to appropriate
services and supports that are responsive to their
needs, generally progressing from less intrusive
to more intensive, and include follow-up/relapse
prevention.
11
Eating Disorders: Best Practices in Prevention and Intervention
Respect for individuality
any number of therapies (ex: cognitive behavioural,
psychodynamic, family, experiential) provided in
various formats. For less complex cases, one or
two therapies may be offered in a time-limited, less
intense format. However, for more complex cases,
therapists tend to use an eclectic approach, including
parts of different models and varying, depending on
individual needs. (Becker, 2003)
While there are commonalities in eating disorders
symptoms, their complexity and multi-faceted
nature require an acceptance of, respect for and
responsiveness to, the unique situation of each
individual.
Honesty
While not definitive, there is evidence supporting
particular therapies as treatments of choice,
depending upon the specific eating disorder and the
age of the individual.
There is irrefutable evidence pointing to the dangers
of eating disorders. This information must be
provided, but in a style that respects contrary beliefs
and encourages testing both sets of beliefs through
individual experience.
However, as emphasized in the 2004 National
Institute of Clinical Excellence (NICE) guidelines: the
absence of empirical evidence for the effectiveness of
a particular intervention is not the same as evidence
for ineffectiveness. (p.9)
Patience and Curiosity
Given the tendency toward uneven progress and
periods of relapse, the most effective therapeutic
approach encompasses patience and curiosity,
and a curiosity about what happened, rather than
impatience or recrimination.
Wherever possible, practice in eating disorders
intervention is guided by clinical research
(randomized controlled trials and well conducted
clinical studies). It is important to recognize that:
An Emphasis on Experimentation
• certain therapies have been the subject
of extensive clinical studies (ex: cognitive
behavioural therapy and pharmacotherapy)
Individuals respond more positively to approaches
that acknowledge the tentative and experimental
nature of the therapeutic process (ex: for each
suggested step, taking a “let’s test this out and see
what happens” approach). In this approach, an
evaluation of results is based on client’s experience
rather than a therapist’s opinions.
• other therapies have only recently been adapted
for eating disorders (ex: motivation enhancement
and dialectical behavioural therapy)
• some therapies have not tended to be subjects
of controlled studies (ex: experiential therapies,
feminist therapy)
Focus on Functionality of Beliefs
At this time, a great deal of practice draws from
expert opinion and well documented clinical
experience (NICE, 2004, APA, 2000). This can be
attributed to the lack of reliable clinical research and
the relative newness of some treatments. It can also
be attributed to the complexity of eating disorders
and the need to individualize treatment by using a
mix of therapies. Gowers (2004) notes that, because
of this reality, established practice guidelines may be
based on best researched rather than best practice
research (p.6).
Given the strong beliefs often held, it works against
the relationship to focus on belief system correctness.
Working to understand the purpose of a belief
system makes possible a level of discussion that
does not occur when the focus is on right or wrong.
The use of an approach that examines positive and
negative aspects of beliefs and behaviours has proven
useful, particularly with anorexia nervosa.
Systematic / Outcome-focus
Asking, rather than telling, is important to keeping
a systematic outcome orientation, in which insights
gained during therapy can be summarized and
applied to everyday life. (Vitousek & Watson, 1998)
The following subsections present a brief summary
of best practice themes that emerge in the literature
reporting on, or reviewing, clinical research and
practice (Appendix 4 provides a brief description of
the therapeutic approaches).
Therapeutic Models/
Approaches
Anorexia Nervosa
There are many therapeutic models/approaches
for treating eating disorders, each with its own
strengths and limitations. Treatment may involve
Appropriate treatment for anorexia nervosa (AN)
continues to be the subject of debate. There remains
a lack of definitive evidence pointing to effective
12
Eating Disorders: Best Practices in Prevention and Intervention
Family Based Therapy
interventions (NICE, 2004; Gowers, 2004; Tozzi et al,
2004).
It is generally agreed that family based therapy is
particularly useful for adolescents (NICE, 2004; Dare
& Eisler, 2002; APA, 2000), and that adolescents
improve more with family treatment than individual
treatment.
Treatment for anorexia is generally divided into three
phases:
• Restoring weight lost due to severe dieting and
purging — there is a strong consensus in the
literature reviewed supporting restoration of
weight in medically fragile individuals before the
therapeutic process begins. Because malnutrition
has an impact on psychological functioning and
cognitive ability, it is argued that individuals need
to be stabilized before psychotherapy is likely to
be effective (NICE, 2004; Becker, 2003; Connors,
2001; APA, 2001).
Benefits cited in family based treatment include:
• enhancing understanding about the eating
disorder and the family member’s experiences
• maintaining positive relationships within families
and addressing family issues that emerge during
treatment
• increasing family capacity to provide the
necessary support to the individual with an eating
disorder
• Treating psychological disturbances such as
distortion of body image, low self-esteem and
interpersonal conflicts — once malnutrition
has been addressed and some level of weight
restoration achieved, treatment usually involves
one or more psychotherapies, selected according
to individual needs.
NICE (2004) recommends that therapeutic
involvement of siblings and other family members
should be considered in all cases because anorexia
nervosa can affect all family members. The guidelines
recommend that children and adolescents be
offered family interventions that directly address the
eating disorder. However, it is also recommended
that children and adolescents be offered individual
appointments in addition to family therapy.
• Achieving long-term remission and rehabilitation
or full recovery — this phase involves provision of
the supports needed to remain well.
The most recent guidelines indicate that anorexia
nervosa can nearly always be treated in the
community on a longer-term outpatient basis. These
guidelines also state that, should individuals with
anorexia nervosa require inpatient treatment, they
should be provided with relevant psychological
interventions (NICE, 2004).
Family therapy may also be beneficial for adults who
have difficult family relationships that contribute to
the perpetuation of an eating disorder.
Interpersonal Psychotherapy
What follows is an overview of guidelines and
research related to specific therapies used in the
treatment of AN.
Interpersonal psychotherapy (IPT) views eating
disorders as an expression of interpersonal difficulties.
It is a non-interpretive, non-directive, short-term
focal psychotherapy that focuses on the interpersonal
issues, and does not deal directly with weight, food
or body image.
Cognitive Behavioural Therapy
Cognitive behavioural therapy (CBT) is not
recommended in the treatment of anorexia nervosa
until weight has been stabilized. The most recent set
of clinical guidelines indicates that rigid behaviour
modification should not be used during inpatient
treatment of anorexia nervosa (NICE, 2004).
There are no controlled studies on the use of IPT
in anorexia. Sources (Becker, 2003; McIntosh et
al., 2000; Apple 1999) note the usefulness of IPT
in addressing underlying issues that trigger and
perpetuate disordered eating behaviours. NICE
guidelines (2004) indicate that IPT may be offered to
adults with anorexia nervosa.
There are findings supporting the use of CBT after
weight stabilization. A recent study (Pike et al,
2003) yielded positive findings for CBT in posthospitalization treatment of adults with anorexia
nervosa. In this study, the group receiving CBT
had lower dropout and relapse rates and better
overall clinical outcomes than the comparison
group receiving nutritional counselling and medical
monitoring.
Psycho-Education
Individuals with eating disorders generally have a lot
of information and misinformation about diet and
weight (Vitousek & Watson, 1998). Specific types
of factual information identified as beneficial for
individuals with anorexia nervosa (as with all eating
disorders) includes:
13
Eating Disorders: Best Practices in Prevention and Intervention
point to findings supporting a group therapy
approach that integrates art therapy, psychodrama
and verbal therapy for adolescents with anorexia
nervosa who may be reticent to engage in more
traditional group therapy.
• physical and psychological consequences of
restrictive eating, binging, purging and low
weight status
• a balanced diet, and the determinants of appetite
and energy expenditure
• genetic influences on body weight, fat distribution
and metabolism
Psychodynamic Therapy
Pike (1998) notes that evidence supports
the usefulness of psychodynamic therapy in
outpatient treatment of anorexia nervosa. Again,
psychodynamic therapy is generally one component
of a more comprehensive treatment strategy
(ex: with behavioural components such as selfmonitoring, cognitive restructuring, relaxation
and assertiveness training). For example, Conners
(2001) points to the benefits of approaches that
integrate cognitive behavioural components
into a psychodynamic framework. Zerbe (1996)
describes the benefits of an approach that combines
psychodynamic and feminist components.
• exercise physiology and mythology
• coping techniques, distress tolerance,
communication and conflict resolution
• identification and celebration of strengths
• life and relationship skills
Motivational Enhancement Therapy
There has been growing interest in Motivational
Enhancement Therapy (MET) in the treatment of
anorexia nervosa. The therapy recognizes resistance
to treatment, identifies an individual’s stage of
change and begins the treatment at that stage.
MET works to help individuals identify their stage
of change and ease their movement through the
stages. MET understands motivation as the product
of a successful interpersonal process, rather than as a
pre-existing individual trait (Kaplan, 2002 as cited in
Wener, 2003).
Feminist Therapy
Therapy that incorporates a feminist perspective
has been identified as useful in working toward
empowerment, celebrating diversity, consciousness
raising, social and gender role analysis, resocialization
and social activism (Peters, 2003). Feminist therapy
helps women take control of their lives in less
destructive ways than through eating disordered
behaviour.
In the initial pre-contemplation stage, the behaviour
is seen as having many rewards and no costs. The
contemplation stage involves recognition of the costs
associated with behaviour along with recognition
of the rewards, but the individual remains uncertain
about whether to change the behaviour. During
the determination and action stage, the individual
resolves the conflict in favour of the benefits
associated with change. Of course, it is rarely a linear
process.
Many practitioners use some of these components
in eating disorders treatment with women. However,
empirical research on feminist practice is in its infancy
(Peters, 2003).
Pharmacotherapy
There is limited evidence in support of
pharmacological treatment of anorexia nervosa, and
pharmacotherapy is not recommended as the sole or
primary treatment for anorexia nervosa (NICE, 2004;
Milan 2002; APA 2000; Attia et al, 1998; Gilchrist et
al, 1998).
A review of MET for anorexia nervosa found that,
while researchers and clinicians are optimistic, at
the time, no randomized controlled trials had been
undertaken (Wener, 2003).
Experiential Therapies
Guidelines (NICE, 2004, APA, 2000) also recommend
that psychotropic medication not be considered
until after weight gain as the weight gain itself may
resolve co-morbid conditions such as depressive or
obsessive compulsive features. At that point, a more
reliable assessment of co-morbid conditions can
occur. Certain serotonin reuptake inhibitors (SSRIs)
may be helpful for weight maintenance and for
resolving mood and anxiety symptoms associated
with anorexia, or when depression precedes its onset
(Zhu & Walsh, 2002; Wilhelm & Clarke, 1998).
Kaplan (2002) notes that, while there is a significant
body of literature on the use of experiential therapies,
such as dance-movement therapy and expressive art
therapy, there are no controlled trials examining their
effectiveness with anorexia nervosa.
Many eating disorders programs have an experiential
therapy component and therapists report it useful
in providing another avenue for accessing internal
processes. Diamond-Raab & Orrell-Valente (2002)
14
Eating Disorders: Best Practices in Prevention and Intervention
• There is a marked need for additional research
into user satisfaction, since it is a key contributor
to positive results.
Practitioners are urged to be cautious in prescribing
medications with side effects that include weight
gain, and to prescribe these only after consultation
with the individual (Becker, 2003).
Bulimia Nervosa
Likewise, careful consideration and caution should
be used before prescribing medications that have
cardiac side effects because of the compromised
cardiovascular function of many people with anorexia
nervosa. If a decision is made to use one of these
medications, ECG monitoring should be undertaken
(NICE 2004).
Compared to anorexia nervosa, there are more
definitive findings regarding bulimia nervosa. These
are outlined below.
Cognitive Behavioural Therapy for
Bulimia Nervosa
Follow-Up/Relapse Prevention
Cognitive behavioural therapy (CBT) has been
studied the most and is widely cited as an effective
treatment for adults with binge/purge symptoms
— with positive results cited for both individual
and group therapy (NICE, 2004; Lilly, 2003; Hay,
2003; ADA, 2001; EDAQ, 2000; APA, 1996; Hay &
Bacaltchuk, 2003; Mitchell et al, 2001).
Themes in the literature reviewed are the importance
of follow-up and relapse prevention measures that
are of long enough duration. For example, Bergh and
colleagues (2002) cite findings pointing to the high
risk of relapse within the first year of remission and
recommend longer-term follow-up.
NICE (2004) guidelines reflect this, specifically stating
that group or individual CBT should be offered to
adults with bulimia nervosa, providing 16 to 20
sessions over 4 to 5 months.
NICE guidelines (2004) recommend that the length
of outpatient psychological treatment following
inpatient weight restoration be a minimum of twelve
months in duration.
Preliminary studies of CBT modified for use with
adolescents, while promising, need to be tested
further (Gowers, 2004; Lock, 2002). Lock (2002)
emphasizes the need to involve and support family
members.
Other findings include:
• A study by Pike (1998) showed that individuals
receiving CBT during a year of relapse-prevention
programming retained significant improvements
in weight restoration, eating behaviour, body
shape and weight concerns, associated pathology
and social functioning.
NICE (2004) guidelines specify that more research
is needed to identify how to address the needs of
the 50 per cent of people with bulimia who do not
succeed with CBT.
• Zhu & Walsh’s review (2002) of recent studies
found that pharmacological interventions oriented
at reducing relapse show promise.
Guided Self-Help
Shortcomings in Anorexia Nervosa Treatment
Research
CBT has been touted as a therapy that can be
simplified for use in non-specialist settings. Guided
self-help, largely informed by CBT, is increasingly
being identified as useful in treating eating disorders.
Benefits cited for guided self-help treatment include
that it:
The most recent guidelines reviewed (NICE, 2004)
highlight the following shortcomings in research
specific to anorexia nervosa:
• There is a need to define specifically the effects of
various treatments as opposed to effects of other
variables such as the experience of the therapist,
duration of treatment and concurrent treatment.
• is relatively brief;
• does not require travel
• is inexpensive
• There is a need to distinguish between therapies
delivered at different stages of treatment.
• does not require specialist time
• There is a need for further exploration of
relapse prevention models that incorporate
pharmacological interventions.
• is simple to disseminate
• is non-stigmatizing, which may benefit those
reluctant to request treatment from specialists
15
Eating Disorders: Best Practices in Prevention and Intervention
• is potentially empowering, and may serve as
a first step in seeking more comprehensive
treatment, if needed
treatment of bulimia nervosa (NICE, 2004; APA,
2000).
Self-help formats (manuals, CD-ROMs), along with
limited guidance from a therapist or other healthcare
practitioner, have been the recent focus of interest
and research (Bailer et al, 2004; Bara-Carril et al,
2004; Ghaderi & Scott, 2003; Carter et al, 2003;
Durand & King, 2003; Thiels et al, 2003; Palmer
et al, 2002). While preliminary, findings have been
generally positive, with reductions in binging and
purging experienced during therapy being retained at
follow-up.
A 2001 randomized controlled study by Safer and
colleagues showed that binge and purge rates
decreased significantly after DBT treatment focused
on teaching adaptive emotion regulation skills.
Dialectical Behaviour Therapy (DBT)
Although preliminary results are promising (Palmer et
al, 2003; Safer et al, 2001), more research is required
to determine who would best benefit from DBT, and
the length and intensity of treatment required.
Exposure and Response Prevention
Researchers are still gathering information about who
might benefit from self-help intervention, and at
what point in the course of a disorder should seeking
self help be encouraged (Garvin et al, 2001).
Research to date indicates that, when used alone,
Exposure and Response Prevention (ERP) does not
appear to be of any benefit and that when used in
concert with CBT, ERP does not appear to affect
results (Hay & Bacaltchuk, 2003; Carter et al, 2002).
The 2004 guidelines by NICE consider guided
self-help a viable treatment and recommend it is
considered as a first step in treating uncomplicated
bulimia nervosa in adults (NICE, 2004).
Psychodynamic Therapy
The benefits of psychodynamic therapy for bulimia
nervosa are the same as for anorexia nervosa. Becker
(2003) suggests that an insight-oriented therapy
aimed at identifying the underpinnings of eating
disordered behaviour may be most useful when
paired with strategies that increase self-observation
and an understanding of the role that the behaviour
plays (Becker, 2003).
Interpersonal Psychotherapy
Sources (NICE, 2004; Becker, 2003; Wilson et al,
2002; Hay & Bacaltchuk; 2001; Agras et al, 2000)
note that IPT takes longer than CBT to achieve
results. However, the retention of benefits is similar
for both therapies.
NICE guidelines (2004) recommend that IPT be
offered as an option for individuals with bulimia
nervosa who have not responded to CBT, or who
wish to be involved in an alternative treatment.
However, the guidelines state that individuals should
be informed that it takes 8 to 12 months to achieve
results, which is a longer period of time than for CBT.
Feminist Therapy
As it is with anorexia nervosa, feminist therapy is
viewed as a useful component of therapy because it
can provide a framework for understanding societal
pressures and it can help with recovery (Conners,
2001).
Pharmacotherapy
Experiential Therapy
Results indicate that antidepressant medication can
reduce the frequency of binge eating and purging,
particularly when used with psychotherapy such as
CBT or IPT (Sloan et al, 2004; Balcaltchuk et al, 2003;
Mitan, 2002; Whittal et al, 1999; Walsh et al, 2000).
Selective Seratonin Reuptake Inhibitors (SSRIs),
particularly Fluoxetine, have been found most
effective, primarily because they have fewer side
effects than other medications (NICE, 2004; APA,
2000), and are approved by the United States Food
and Drug Administration (FDA) for the treatment of
bulimia nervosa in adults (Zhu & Walsh, 2002).
Experiential therapy components such as art,
psychodrama and creative movement, are parts of
many treatment approaches for bulimia nervosa.
As in anorexia nervosa treatment, they are cited as
useful in augmenting the effectiveness of verbal
therapy (Diamond-Raab & Orrell-Valente, 2002;
McComb & Clopton, 2003).
Follow-Up/ Relapse Prevention
The importance of proactive, planned relapse
prevention is highlighted in a study by Mitchell and
colleagues (2004), which found that simply telling
individuals with bulimia nervosa to come back if they
Other medications have been studied, but only
antidepressants are currently recommended for
16
Eating Disorders: Best Practices in Prevention and Intervention
have problems is not an effective relapse prevention
technique (p.549). The authors recommend return
visits that are planned in advance, or follow-up phone
calls.
The NICE guidelines (2004) recommend that
cognitive behaviour therapy adapted for binge eating
disorder should be offered to adults with binge eating
disorder.
The following are also identified as useful
components in proactive follow-up/relapse
prevention:
Guided Self-Help
Guided self-help is increasingly being considered as a
treatment of choice for uncomplicated binge eating
disorder, particularly in situations where therapists
are not easily available or associated costs such as
travel are prohibitive (Palmer, 2002; Loeb et al, 2002;
Peterson et al, 2001; Kotwal, 2004).
• aftercare plans that involve the general
practitioner, school staff, friends, family and the
person with the eating disorder
• referral to a self-help consumer-based
organization can be extremely helpful and a
source of ongoing information, support and
assistance
Positive results have been cited for both guided and
unguided self-help, including:
• for women who are mothers, interventions aimed
at assessing and responding to the needs of
family members
• improved eating behaviour
• elimination of inappropriate compensatory
behaviours
• education, support and therapy that helps family
and friends understand and help with recovery
(EDAQ, 2000)
• reduction in shape and weight concerns and other
symptoms of psychopathology
• improved general physiology
Binge Eating Disorder
The NICE guidelines (2004) suggest that CBT
for binge eating disorder in a self-help format be
considered as a possible first treatment, along with
direct encouragement and support provided by
health care professionals.
Binge eating disorder is the most recently identified
eating disorder and research into effective treatments
is still very preliminary. Levine and colleagues (2003)
indicate that a number of the treatments are similar
to those for bulimia nervosa, with some adaptations.
Interpersonal Psychotherapy (IPT)
Cognitive Behaviour Therapy for Binge
Eating Disorder
Clinical research and experience supports the use
of IPT in the treatment of binge eating disorder.
Studies (Kotwal et al, 2004; Levine et al, 2003;
Wonderlich et al, 2003; Hay & Bacaltchuk, 2001;
Wilfley et al, 2002; Wilfley et al, 1997) indicate that,
for individuals who received group interpersonal
psychotherapy, binge eating remained significantly
below baseline at the six-month and one-year follow
up periods.
As with bulimia nervosa, clinical evidence supports
the use of CBT for treating binge eating disorder.
Levine et al (2003) cite some notable differences
between CBT for binge eating disorder and bulimia
nervosa, specifically that:
• Despite early cautions around reducing calories,
evidence to date suggests that decreasing caloric
intake and increasing dietary restraint in a weight
control program does not exacerbate binge
eating.
Pharmacotherapy
As with bulimia nervosa, pharmacological treatment
for binge eating disorder may be a useful adjunct
to psychological therapies. SSRIs have been studied
most extensively and there is some evidence that
Buproprion may be useful in addressing depression
in individuals with binge eating disorder, and that
anticonvulsants may be useful for treating cooccurring bi-polar disorder.
• Cognitions related to having a large body size can
be directly targeted in treatment. Individuals can
be encouraged to work toward acceptance of a
larger body size and to restructure maladaptive
thoughts about a realistic level of weight loss.
A recent study by Wilfley and colleagues (2002)
indicated that, for individuals who received CBT,
binge eating remained significantly below baseline at
the six-month and one-year follow up periods.
Zhu & Walsh (2002) note the benefit of combining
medication with psychotherapy. They also note
that sole reliance on medication may prevent
17
Eating Disorders: Best Practices in Prevention and Intervention
Feminist Therapy
development of the psychological tools needed to
deal successfully with binge eating disorder in the
long term.
Literature reviewed on binge eating disorder did
not address the use of feminist therapy. However,
as with anorexia nervosa and bulimia nervosa,
feminist therapy would have the capacity to provide
a relevant framework within which women can
empower themselves and work toward recovery.
Experience to date shows that a combination of
CBT and antidepressant therapy can reduce binge
frequency. However, this approach remains unproven
in controlled trials (Kotwal et al, 2004).
Dialectical Behaviour Therapy
Experiential Therapy
A modified version of dialectical behaviour therapy
(DBT) also appears promising in treating binge eating
disorder. Telch and colleagues (as cited in Levine,
2003) adapted and tested a group-based version
of DBT and found it to be effective in reducing
binge eating behaviour and decreasing maladaptive
attitudes about eating, shape and weight. Other
studies (Safer et al, 2001; Palmer, 2002) have also
yielded promising results.
As in anorexia nervosa and bulimia nervosa
treatment, experiential therapies provide an
additional mechanism for self-discovery and the
identification of issues that need to be addressed
before recovery can begin (Riva et al, 2003).
Follow-up/Relapse Prevention
As with all eating disorders, a proactive plan for
relapse prevention is an essential part of treatment.
NICE guidelines (2004) recommend that, following
intensive treatment, active relapse prevention
planning should be a minimum of 12 months in
duration.
More research is needed on length, intensity and the
identification of which individuals would benefit most
from DBT. The NICE guidelines (2004) recommend
that modified DBT be offered to adults with
persistent binge eating disorder.
Psychodynamic Therapy
The literature reviewed was silent on psychodynamic
therapy for binge eating disorder.
18
Eating Disorders: Best Practices in Prevention and Intervention
Type of
Treatment
Aims of Intervention
Restore weight (AN); reduce binge eating and purging (BN); normalize eating patterns;
achieve normal perceptions of hunger and satiety; correct biological and psychological
complications of malnutrition.
Nutritional
Rehabilitation
Psychosocial
treatments
Enhance motivation; increase self-esteem; teach assertion skills and anxiety
management techniques; improve interpersonal and social functioning; treat co-morbid
conditions/clinical features associated with eating disorders.
CognitiveBehavioural Therapy
(CBT)
Reduce binge-eating and purging behaviours (BN); improve attitudes related to
eating disorders; minimize food restriction; increase variety of foods eaten; encourage
healthy but not excessive patterns; address body image concerns, self-esteem; affect
regulation, coping styles and problem solving.
Family Therapy
Teach families how to express emotion, set limits, resolve arguments and solve
problems effectively; increase parents’ understanding of the difficulties of the affected
child; avoid a view of the world where success or failure is measured in terms of
weight, food and self-control.
Feminist therapies
Address role conflicts, identity confusion, sexual abuse and other forms of victimization
in the development, maintenance and treatment of eating disorders; emphasize the
importance of women’s interpersonal relationships.
Interpersonal
Psychotherapy (IPT)
Help to identify and modify current interpersonal problems; identify and improve
underlying difficulties for which eating disorders constitute a maladaptive solution;
improve insight into interpersonal difficulties and motivation.
Interpersonal
Psychotherapy (IPT)
As above for CBT, IPT and feminist therapy, depending on approach taken; provide
information, support and help for individuals to more effectively deal with the shame
surrounding their problem, as well as provide additional peer-based feedback and
support.
Group Therapy
As for CBT (BN): improve eating, reduce binging and inappropriate compensatory
behaviours, reduce shape and weight concerns, and improve general psychological
outlook which can be a valuable adjunct to most forms of treatment.
Self-Help and
Guided Self-Help
As for CBT (BN): improve eating, reduce binging and inappropriate compensatory
behaviours, reduce shape and weight concerns, and improve general psychological
outlook which can be a valuable adjunct to most forms of treatment.
Medications
Treat other psychiatric problems associated with the eating disorders — after weight
restoration (AN), or in combination with psychological approaches (BN) such as
depression.
Therapeutic Approaches to Treating Eating Disorders
19
Eating Disorders: Best Practices in Prevention and Intervention
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